Structural Factors Contributing to Compassion Fatigue,Burnout,and Secondary Traumatic Stress Among Hospital-Based Healthcare Professionals During the COVID-19 Pandemic

Abstract

High levels of burnout among healthcare providers (HCPs) have been a widely documented phenomenon, which have been exacerbated during the COVID-19 pandemic. In the United States, qualitative studies that are inclusive of HCPs in diverse professional roles have been limited. Therefore, we utilized a qualitative–quantitative design to examine professional quality of life in terms of compassion fatigue, burnout, and secondary traumatic stress among hospital-based HCPs, including social workers, hospitalists, residents, and palliative care team members during COVID-19. HCPs (n = 26) participated in virtual semi-structured focus groups or individual interviews and online surveys (n = 30) including the Professional Quality of Life (ProQOL) Scale. While ProQOL scores indicated low levels of compassion fatigue, burnout, and secondary traumatic stress, thematic analysis of our qualitative data included rich descriptions of compassion fatigue, burnout, and secondary traumatic stress. Safety concerns and value misalignment characterized structural stressors perceived to contribute to HCP compassion fatigue, burnout, and secondary traumatic stress. The discrepancy between our qualitative and quantitative findings may be indication that modifications to current screenings are warranted. These findings also suggest a need to identify and implement structural and policy changes that increase HCPs’ physical and emotional safety and promote better alignment of institutional interests with HCP values.

Keywords

compassion fatigue burnout secondary traumatic stress healthcare professionals COVID-19

Introduction

The COVID-19 pandemic has overwhelmed healthcare systems and further exposed healthcare disparities disadvantaging historically marginalized populations (Hooper et al., 2020; Yancy, 2020). Healthcare professionals (HCPs) have been tasked with delivering intensive clinical care on an unprecedented scale while adapting to the pandemic’s disruption of personal, professional, and social life. Consequently, HCPs’ professional quality of life has been adversely affected, as evidenced by heightened levels of compassion fatigue, burnout, and secondary traumatic stress (Alanazi et al., 2022; Braquehais et al., 2020; Koontalay et al., 2021; Lluch et al., 2022). In the United States (U.S.), there has been limited qualitative and mixed-methods studies that include HCPs in roles other than nurses and physicians (Chen et al., 2021; Pearman et al., 2020; Rodriguez et al., 2020; Shechter et al., 2020).

HCP Compassion Fatigue, Burnout, and Secondary Traumatic Stress

Prior to COVID-19, HCPs in the U.S. were experiencing burnout at alarmingly high rates, ranging between 40% and 54% for physicians, 35% and 45% for nurses, and 45% and 60% for medical students and residents (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019). HCP burnout rates have increased since 2020 in the U.S., with a report between June and September of 2020 showing that 76% of sampled HCPs had experienced burnout (Mental Health America, 2022). Another study found that emotional exhaustion increased for hospital-based HCPs across the pandemic (Sexton et al., 2022).

Similarly, secondary traumatic stress has been well documented among healthcare professionals such as physicians, nurses, and social workers (Badger et al., 2008; Nimmo and Huggard, 2013; Zhang et al., 2018). Of 596 nurses who participated in a study assessing trauma, burnout, and posttraumatic stress during the pandemic in China and Taiwan, 13.3% reported symptoms of traumatic stress (Chen et al., 2021). A U.S. study found that 41% of HCPs reported symptoms of secondary traumatic stress, which was higher among those who had been frontline workers exposed to death (Orrù, 2021). In a study assessing burnout and compassion fatigue among hospital-based nurses in one U.S. health system, 86% of emergency-room nurses indicated moderate to high levels of compassion fatigue and 82% indicated moderate to high levels of burnout (Hooper et al., 2010).

Low professional quality of life in terms of compassion fatigue, burnout, and secondary traumatic stress has individual- and systems-level consequences. For example, compassion fatigue has been associated with increased irritability, reduced standard of care, negative patient experiences, or diminished workforce capacity due to early retirement (Dasan et al., 2015). Not only does burnout translate into poor mental health outcomes for HCPs such as substance abuse and suicidality, but it also adversely impacts clinical care, increasing the incidence of errors, malpractice claims, staff turnover and absenteeism, and patient dissatisfaction (NASEM, 2019; Pearman et al., 2020; Shah et al., 2022).

The implications for staff turnover and early retirement are especially concerning considering staff shortages already afflict the U.S. healthcare system and are expected to worsen—the American Association of Medical Colleges (2020) predicted a shortage of up to 139,000 physicians by 2033. Another study reported there will be significant shortages of nursing staff throughout the U.S. until 2030 (Juraschek et al., 2019). Similar projections have been made regarding other roles including nursing and medical assistants (Bateman et al., 2021). Burnout and high stress were the top reasons cited by nurses looking to leave the profession (Incredible Health, 2021). The U.S. Surgeon General has declared HCP burnout a public health crisis and warned that failure to intervene will negatively impact all aspects of healthcare as staffing shortages will lead to delays in care, costs increases, and worsening disparities (Office of the United States Surgeon General, 2022).

Theoretical Framework

Stamm’s (2010) model characterizes professional quality of life or “the quality one feels in relation to their work as a helper” (p. 8) as influenced by one’s experiences of compassion satisfaction/fatigue, burnout, and secondary traumatic stress. In this model, burnout and secondary traumatic stress have been conceptualized as elements of compassion fatigue or the low end of the compassion satisfaction continuum, which is “about the pleasure you derive from being able to do your work well” (Stamm, 2010, p. 12). Burnout is associated with feeling exhausted, frustrated, angry, and unable to effectively do one’s job (Stamm, 2010). Secondary traumatic stress is related to work-related experiences of fear and exposure to individuals who have been traumatized (Stamm, 2010).

The Present Study

It is imperative to have a clear understanding of the factors that impact professional quality of life among HCPs in the U.S., so interventions can be strategically tailored to improve outcomes. There has been a larger discussion about the role of structural factors, such as heavy workload, administrative burden, inefficient technologies, and inadequate staffing and resources, in HCP burnout (NASEM, 2019; Shanafelt & Noseworthy, 2017). Yet, these structural factors have not been widely incorporated into prevention programs or burnout interventions at the organizational level. Drawing from a social constructivist epistemology, which acknowledges the varied subjective meanings of people’s experiences while taking into account the contexts in which people exist (Creswell & Poth, 2017), we utilize Stamm’s professional quality of life theoretical model and screening (Stamm, 2010) to better understand the impact of COVID-19 among hospital-based HCPs. We draw on the accounts of HCPs from diverse professional backgrounds, including social workers, nurses, residents, and doctors to assess and describe HCPs’ professional quality of life in terms of compassion fatigue, burnout, and secondary traumatic stress during the pandemic. Our research questions are: (1) What levels of compassion fatigue, burnout, and secondary traumatic stress did HCPs experience during the COVID-19 pandemic? and (2) What factors contributed to HCP compassion fatigue, burnout, and secondary traumatic stress during the pandemic?

Methods

Study Design

A concurrent, explanatory qualitative + quantitative mixed-methods design (Creswell & Creswell, 2018; Morse & Cheek, 2014) was used to provide a thorough understanding of HCPs’ professional quality of life during the COVID-19 pandemic in terms of compassion fatigue, burnout, and secondary traumatic stress (Stamm, 2010). Quantitative and qualitative data were collected and analyzed separately and integrated through triangulation in the interpretation phase (O’Cathain et al., 2010).

Author Positionality

The research team was interdisciplinary and included faculty physicians, social scientists, hospital staff, and graduate students. During team meetings, the authors reflected on their positionality and how it informed their perspective on the various stages of research. At the time of data collection and analysis, the lead author was a social work doctoral student. She had no prior relationship with research participants and was not an employee or a trainee at the institution where the study took place. The second author was a social work doctoral candidate who had no prior relationship with the participants. To minimize potential effects of social desirability, authors who were faculty or staff at the institution where the study took place did not conduct data collection but limited their roles to study design, recruitment, secondary analysis, and manuscript development.

Ethics

This study was granted exempt status by the university’s Institutional Review Board as it was part of a quality improvement study aiming to evaluate various outcomes of a community health worker intervention, including its impact on HCP compassion fatigue, burnout, and secondary traumatic stress. All participants provided written informed consent. Given the small sample size and its connection to only one institution, to protect participants’ identities, participant quotes were modified by substituting references to specific roles by the descriptors ‘hospitalist’, ‘resident’, or ‘non-physician’.

Sampling

A purposive, non-probabilistic sampling approach was used to recruit HCPs from an urban academic safety-net hospital located in the U.S. South. This setting was selected because it was the site of a larger project involving community health workers addressing COVID-19 impacts on Latinx patients. Our team emailed a flyer to hospital listservs that included 63 HCPs from various departments, inviting them to participate in a focus group and survey about their experiences during the pandemic. The recruitment flyer included a link to the consent form, a survey with demographic questions, and the ProQOL (Stamm, 2010).

Thirty HCPs consented, completed the quantitative portion of the study, and were invited to participate in a focus group. All thirty participants met study’s inclusion criteria of being fluent in English and having been an employee or trainee at the institution for at least 6 months. To minimize potential effects of social desirability, community health workers were not included in this set of focus groups as the primary purpose of this study was the evaluation of a community health worker intervention. Taking into consideration HCPs’ limited time availability during the pandemic, HCPs who could not attend a focus group were offered an individual interview in order to maximize participation. Only two HCPs participated in individual, semi-structured interviews. Of the thirty HCPs who consented and completed the survey, twenty-three participated in one of five focus groups which were disaggregated by role (hospitalists, residents, and others) to prevent power dynamics from affecting how HCPs participated. No HCP attended more than one focus group. The number of participants in each focus group ranged from two to eight. Details about composition of focus groups can be found in Table 1.

Table 1.

Focus Group Attendance (n = 23).

Focus group ID	Participants role	Number of participants
FG1	Non-physicians	5
FG2	Non-physicians	3
FG3	Residents	8
FG4	Residents	2
FG5	Hospitalists	4

Study Procedures

Quantitative Procedures

Participants were asked their age, gender, race/ethnicity, professional role, and years in healthcare. Professional quality of life, as conceptualized by Stamm (2010), was measured in terms of compassion fatigue, burnout, and secondary traumatic stress via the ProQOL Scale, a standard measure designed to assess these outcomes among those in helper roles (Stamm, 2010). The ProQOL has been used internationally for over 25 years (Stamm, 2010). It includes 30 Likert scale questions and three subscales: Compassion satisfaction/fatigue, burnout, and secondary traumatic stress. For the compassion satisfaction/fatigue subscale, high scores indicate compassion satisfaction and low scores indicate compassion fatigue. For the burnout and secondary traumatic stress subscales, high scores indicate high levels of burnout and secondary traumatic stress. The ProQOL has good reliability based on the original normed sample (Stamm, 2010). We also calculated Cronbach’s alphas with our sample across all three subscales (.84).

Descriptive statistics were calculated in SAS software (S.A.S. Institute Inc, 2013) for sociodemographic characteristics and the primary outcomes of compassion fatigue, burnout, and secondary traumatic stress. Univariate frequency distributions were conducted on all baseline outcome variables. Due to the small sample, only descriptive analyses were conducted.

Qualitative Procedures

A semi-structured interview guide was developed with 13 questions designed to elicit participants’ constructed meaning of the impact of the COVID-19 pandemic on them. Questions included “How has COVID-19 impacted your role as a healthcare professional?” and “How has working in a hospital during the pandemic affected you personally?” A script was prepared to be used at the beginning of each focus group and interview clarifying the study’s purpose and confidentiality agreement and providing an opportunity for participants to ask questions. Utilizing the interview guide, the second author facilitated five virtual focus groups and two virtual individual interviews, each lasting approximately 50 minutes, in October and November of 2021. Each participant received a $25 electronic gift card as compensation. All focus groups and interviews were conducted in English, audio-recorded via Zoom, and transcribed verbatim. The first and second authors checked the transcripts for accuracy and to ensure the proper identification of participants. Data were then de-identified and loaded into NVivo (QSR International, 2020).

Inductive thematic analysis (Braun & Clarke, 2006; Guest et al., 2012) was used as it suited the study’s social constructivist epistemology (Creswell & Poth, 2017) and the study’s purpose of eliciting HCPs’ description of their experiences during COVID-19 not based on a hypothesis defined a priori. The first author read each transcript, wrote memos, generated preliminary codes, and formatted a codebook. Codebook development was an iterative process of coding a transcript, editing the codebook, consulting with other team members, and reviewing previously coded data. The codebook became stable after five transcripts, indicating conceptual saturation had been reached, meaning that no major changes to codes and their definitions were needed (Guest et al., 2012). The result of these activities was 13 stressors grouped in three different domains. Codes were then analyzed in relation to each other. This resulted in two common themes being identified, namely, safety concerns and value misalignment. All coded data was then reviewed to assess whether and how stressors related to these two common themes.

Peer debriefing was utilized on four occasions. Analytic processes and decisions as well as reflections and feedback from peer debriefing were documented in an audit trail. To further validate this study’s findings, member checking was conducted. All HCPs who signed a consent form (n = 30) were emailed a summary of the preliminary findings and invited to participate in a focus group or provide written feedback regarding their perceptions of the preliminary findings (Birt et al., 2016). During a 60-minute member checking group, three HCPs confirmed that the preliminary findings accurately described their experiences. Another HCP provided positive feedback regarding the preliminary findings via email. No significant adjustments to the findings were required as a result of member checking.

Mixed-Methods Procedures

Discrepancies between quantitative and qualitative findings were addressed through the applicable strategies suggested by Moffatt et al. (2006): (1) treating the methods as fundamentally different; (2) exploring the methodological rigor of each component; (3) exploring dataset comparability; and (4) exploring whether the outcomes of the quantitative and qualitative components match.

Findings

Quantitative and qualitative findings are first reported separately and then integrated.

Quantitative Findings

All participants (n = 30) were HCPs at an urban academic safety-net hospital in the U.S. South (refer to Table 2 for sample demographics). ProQOL scores were within the moderate range on compassion satisfaction/fatigue (

\bar{X}

= 39.7, SD = 4.8) and within the low range for burnout (

\bar{X}

= 25.4, SD = 5.7) and secondary traumatic stress (

\bar{X}

= 27.4, SD = 5.6; Table 3).

Table 2.

Sample Demographics (n = 30).

Variables	Number (%)
Age (mean)	35.2
Gender (female)	19 (73%)
Race
White	21 (81%)
Black	1 (4%)
Asian	4 (15%)
Hispanic or Latinx	5 (20%)
Spanish speaking	8 (31%)
Professional background
Physician	6 (23%)
Resident physician	12 (46%)
Nurse	3 (12%)
Social worker	3 (12%)
Advanced practice nurse	1 (4%)
Chaplain	1 (4%)
Years in healthcare (mean)	7.5

Table 3.

Compassion Fatigue, Burnout, and Secondary Traumatic Stress Among Healthcare Professionals (HCPs) Based on the ProQOL (n = 30).

Variables	Mean (SD)	Range	Cronbach’s alpha
Compassion satisfaction^a	39.7 (4.8)	29–50	.84
Burnout^b	25.4 (5.7)	13–41	.84
Secondary traumatic stress^b	27.4 (5.6)	16–43	.84

^aLower scores indicate compassion fatigue (22 or less).

^bHigher scores indicate burnout and secondary traumatic stress (42 or more).

Qualitative Findings

During virtual focus groups and interviews, HCPs (n = 25) described experiences typical of compassion fatigue, burnout, and secondary traumatic stress, at times explicitly naming these outcomes. Two major themes characterized the stressors contributing to HCPs’ self-reported compassion fatigue, burnout, and secondary traumatic stress: (1) Safety concerns and (2) value misalignment. The theme of safety concerns was defined as assessing for, worrying about, or taking steps to ensure the physical and psychological safety of self and others. The theme value misalignment was defined as a mismatch between an HCP’s personal and professional values and those of the hospital or society. Below, we describe these themes and how they manifested across the 13 stressors, which were categorized as COVID-19 specific, institution specific, and society specific (Tables 4 and 5).

Table 4.

Definitions and Categorization of Stressors Experienced by HCPs During the COVID-19 Pandemic Contributing to Compassion Fatigue, Burnout, and Secondary Traumatic Stress.

COVID-19-specific stressors	Institution-specific stressors	Society-specific stressors
Unpredictability: Being unable to predict the future regarding patient outcomes as well as the pandemic itself	Heavy workload: Having a workload that cannot be completed within normally scheduled hours or with reasonable effort	Neglect of public health safety measures: To perceive COVID-19’s impact as small, not significant. To be neglectful of taking precautions such as masking and avoiding social gatherings
High death rate: High number of patients dying from COVID-19	Compensation and benefits: Issues related to pay rates and benefits	Vaccine hesitancy: To hesitate or refuse to get a COVID-19 vaccine
Difficult conversations: Communicating with patients’ loved ones about no-visitor policy, patients’ poor health, worsening condition, end-of-life decisions, and death	Toxic environment: Negative interactions or feelings between employees and/or between employees and leadership	COVID-19 denialism: To deny that COVID-19 is real, to attribute it to a political movement or agenda
Patient isolation: Witnessing and/or mitigating patient isolation by being present with patients and/or facilitating patient communication with loved ones		Healthcare disparities: Patients’ treatment quality varying according to their socioeconomic status
HCP isolation: Physical and psychological isolation fueled by limited in-person social interactions as well as a heightened awareness of COVID-19’s impact
Risk of spread: Chance of catching COVID-19 at work; chance of exposing others to COVID-19

Table 5.

Presence of Safety Concerns and Value Misalignment Within Stressors Experienced by HCPs During the COVID-19 Pandemic.

Category	Stressor	Safety concerns	Value misalignment
COVID-19 specific	Unpredictability	X	X
	High death rate	X	X
	Difficult conversations		X
	Patient isolation		X
	HCP isolation	X	X
	Risk of spread	X
Institution specific	Heavy workload	X	X
	Compensation and benefits		X
	Toxic environment	X	X
Society specific	Neglect of public health safety measures	X	X
	Vaccine hesitancy	X	X
	COVID-19 denialism	X	X
	Healthcare disparities	X	X

Theme 1: Safety Concerns

Thoughts, feelings, and practices focused on assessing and ensuring physical and emotional safety were constantly at the forefront of HCPs’ experiences during the COVID-19 pandemic, contributing to HCP compassion fatigue, burnout, and secondary traumatic stress.

COVID-19-Specific Stressors

Stressors such as the risk of spreading the infection and its high death rate posed concerns for physical safety. Paradoxically, the safety measures needed to prevent spread, namely, HCP and patient isolation, posed concerns for psychological safety and wellbeing. Chronically having to assess and mitigate issues of basic safety negatively impacted HCPs’ psychological wellbeing. One participant described her intense emotional reaction to realizing she had exposed others to COVID-19:

I had a full mental breakdown thinking that I could have possibly given it to my family. It had been when I was wedding-dress shopping that weekend, (…) I was masked and stuff, but still the thought that I could have given it to someone just petrified me. (Resident 1)

As she tried to make sense of her experience, this participant compared her reaction to PTSD, alluding to the trauma she had endured as an HCP, while indicating the weight of the safety concerns and resulting practices she had been carrying:

I honestly was having really dark depressing thoughts. I think it was definitely like PTSD from seeing everyone dying, feeling the shame of having COVID. I’ve been so careful all year, I was so careful. I had a low-risk exposure at work, I just didn’t expect it and I had gotten tested, but my test got lost. And I just felt so much shame and anger and defeat. And it was horrible. It was horrible. (Resident 1)

The high mortality rate of COVID-19 patients was a constant reminder of the safety threat at hand: “We were inundated by deaths on all sides” (Non-physician 1). Safety was also compromised in the unpredictability of the pandemic, leading HCPs to feeling “scared about the future because we don’t know when it’s gonna end” (Resident 2). Unpredictability was also relevant in terms of how COVID-19 progressed as a disease in patients: “I would go in every day not knowing which one of my patients is going to get worse, which one of them is going to die” (Resident 3). Worrying about and assessing for safety was an ever-present physical and mental practice for HCPs, which contributed to compassion fatigue, burnout, and secondary traumatic stress.

Institution-Specific Stressors

Safety concerns were present in two of the three institution-specific stressors: Heavy workloads and toxic work environment. Worrying about keeping everyone safe while being overextended contributed to burnout: “Everyone was burnt out at some point during my second year because we were forced to do so many extra shifts” (Resident 4). Residents reported doing several extra weeks of ICU rotation and taking additional responsibilities to meet patients’ needs and support faculty mentors.

Negative interpersonal dynamics among HCPs and between HCPs and hospital leadership added a sense of feeling emotionally unsafe. One participant elaborated on the increased potential for errors resulting from the hospital’s challenges in hiring and retaining staff and its implications for care. She commented, “The staff that work here want to do a good job, but sometimes we feel almost restrained by our own administration” (Non-physician 1). Pay disparities were also mentioned as a component of the toxic work environment: “There are people who are working to be understanding and compassionate who also know that that we are never the people that receive extra compensation or bonuses. It’s a really complicated time around staffing and pay” (Non-physician 2). Another participant reflected, “We used to pride ourselves on the relationships [among providers] […] it’s now almost a toxic environment with much more mistrust, a lot of finger-pointing” (Hospitalist 1).

Society-Specific Stressors

All society-specific stressors identified were underpinned by safety concerns. HCPs felt unsafe both at work and outside of work, which was perceived to contribute to compassion fatigue, burnout, and secondary traumatic stress. Beyond the obvious concern for the safety of the community related to transmission, neglect of public health safety measures, vaccine hesitancy, and COVID-19 denialism also brought a concern for personal safety, as HCPs were often viewed antagonistically by a segment of society. One participant mentioned, “We have had more anger directed at us about any of a number of things related to COVID. And I know providers that have had been in scrubs at gas pumps getting yelled at” (Non-physician 2).

Finally, healthcare disparities among marginalized patients were another society-specific stressor characterized by safety concerns. One participant reflected, “I very rarely have any confidence that the person that I’m discharging from the hospital is going to actually get the type of follow-up and services that I think they need” (hospitalist 3). Another participant recounted:

Simple things like in the beginning, we knew patients needed oxygen to go home safely, because that was one of the few therapies that works [for COVID-19], and having to argue with our hospital systems that oxygen should be provided, (…) to me just seemed crazy. (Hospitalist 2)

The exacerbation of healthcare disparities among underserved patients during the COVID-19 pandemic was perceived to directly contribute to HCPs’ low professional quality of life.

Theme 2: Value Misalignment

Due to a variety of institutional and societal circumstances, HCPs were prevented from living and working according to their values, which HCPs related to compassion fatigue, burnout, and secondary traumatic stress.

COVID-19-Specific Stressors

Restrictions, such as not permitting in-person visitors, required HCPs to deliver care in ways that, in addition to being different from what they were used to and trained for, were also misaligned with their values for patient care. For example, HCPs talked about how impersonal it felt to discuss end-of-life issues with patients’ families over the phone: “It was almost trying to convince them (loved ones) ‘he’s really sick, I’m not lying to you’. It was really challenging” (Resident 3). They also talked about the hardship of witnessing patients dying alone. Facilitating a patient’s goodbye to his family via video call felt like a traumatizing moral obligation to this participant:

I was in a COVID room, geared up head-to-toe, super-hot, sweaty, tired. And the last two hours of this man’s life, I held up the iPad, so his family can see him. (…) I have this firsthand view to their active grieving and I can’t, I can’t leave. If I leave, they end the call. I need to be there, and it’s just so traumatizing. (Non-physician 1)

Likewise, when talking about the high number of patient deaths and difficult conversations she had to navigate, a participant said, “One adjective that I often use to describe it when talking about it with other people is that it’s been traumatic” (Resident 7). The very procedures in place to ensure safety, at times, were perceived to contribute to compassion fatigue, burnout, and secondary traumatic stress among HCPs.

Institution-Specific Stressors

HCPs reported inadequate financial compensation and benefits coupled with excessive workloads and increased roles and responsibilities during the COVID-19 pandemic. One participant stated, “[COVID-19] added probably 10 more hours of meetings and work a week and a leadership role that wasn’t compensated or accounted for by the hospital” (Hospitalist 4). Reflecting on the increased amount and intensity of the work, another participant stated, “It’s been incredibly taxing on our hospitalist group, our group of infectious disease doctors, and our residents to the point where people are pretty much burnt out” (Hospitalist 1). He later described how burnout manifested in the team and its potential consequences:

[HCPs are] not interested in any more change or innovation or additional responsibilities. Getting faculty to step up now to do additional faculty type work, you might expect as part of being faculty, it’s just hard, people just don’t really want to give more. (Hospitalist 1)

This participant speculated that the generalized burnout may generate additional institution-specific stressors such as potential challenges around opportunities for student mentoring and learning.

The pay gap between travel nurses and staff nurses played a role here, too, as voiced by one participant: “It does feel like a slap in the face when someone who could have left for more money, stayed out of loyalty, and then didn’t get rewarded financially for that” (Non-physician 1). The hospital’s practice of offering a competitive pay to attract travel nurses and alleviate workload issues translated into an undervaluing of staff nurses’ loyalty to the institution.

Another participant described how assisting socioeconomically vulnerable patients and loved ones required much time and energy and expressed, “It just feels like the whack a mole, you can’t come up for air without being pushed down. It’s just very, very PTSD” (Non-physician 1). Yet, additional patient demands did not elicit additional institutional support in terms of increased benefits or pay. One participant talked about how HCPs were not provided extra sick leave when they or their dependents contracted COVID-19, forcing HCPs to use their paid time off for this purpose. She reflected “We’ve been compensating for a system that’s not really taking care of us” (Non-physician 3). Agreeing with the structural nature of the stressors contributing to compassion fatigue, burnout, and secondary traumatic stress, another participant stated, “I’m not just a couple of yoga classes away from feeling top-notch, it’s way more systemic than that” (Non-physician 2).

It is important to note that while safety concerns stood out as a theme on its own, safety as a value that could not always be upheld to a desired level also played a role in the misalignment of HCP values. One participant summarized:

There are providers that have had (patient) numbers that if we had more staffing would not be anybody's choice (…). And that is an added layer of stress, concern, fear, burnout, anxiety, a sense of not being valued, appreciated or seen, right? For the folks who are there to feel like they’re in a place to not deliver the care they want to and feeling worried that it’s unsafe. (Non-physician 2)

Heavy workload, in addition to being physically exhausting, included layers of safety concerns and value misalignment at the institutional level.

Society-Specific Stressors

HCPs had to grapple with the dissonance between their own values and the values of members of society who (1) neglected public health safety measures, (2) hesitated or declined to get vaccinated, and/or (3) denied the existence of COVID-19. One participant recalled, “I posted a picture on social media of my first dose of the COVID vaccine, I had a lot of people almost attacking me like, ‘Oh, my goodness, why would you get this? Do you know what’s in this?’” (Resident 5). Society’s disregard for scientific knowledge was viewed as an obvious misalignment of values by most HCPs: “The vaccine is free, it’s available, you could have easily gotten it. It was just a bit more challenging, to share the same compassion I had during the first surge” (Resident 3). Another participant captured the emotional toll this dissonance had taken, alluding to an experience of compassion fatigue and burnout:

I’m running out of the patience, the empathy, the understanding, to try to sit there and hear more conspiracy theories, hear more people denouncing my profession, my work. I’m willing to work 80 hours a week and get training to help people and then people just write it off with something they read on the internet. (Resident 6)

The misalignment between HCPs and societal values was also made evident by the fourth of society-specific stressors, healthcare disparities. HCPs agreed that the pandemic made pre-existing inequities in the healthcare system undeniable, creating a moral struggle for HCPs. One participant stated, “The number of disparities that we knew about, and became worse, was really striking and demoralizing” (Hospitalist 2). One participant highlighted the emotional toll this value misalignment took:

Knowing what the right thing to do or to give or what someone needs and then not being able to deliver that causes not just dissatisfaction, but it leads to feeling upset, feeling inadequate, feeling mad at the system, feeling helpless, I, you feel hopeless a lot about being victims of the way the system is set up. (Hospitalist 3)

In practice, this translated into HCPs grappling with the dissonance between their values and what the healthcare system allowed them to do, which was perceived to contribute to low professional quality of life.

While our quantitative findings indicated moderate to low levels of HCP compassion fatigue, burnout, and secondary traumatic stress, our qualitative data revealed clear examples of HCP compassion fatigue, burnout, and secondary traumatic stress which were connected to stressors characterized by safety concerns and value misalignment. The application of Moffatt et al.’s (2006) strategies indicated that this discrepancy could be attributed to a mismatch between how the outcomes were operationalized and measured in the ProQOL survey versus how the real-life experience of these outcomes was felt and described by HCPs. Of note, most of the stressors described by HCPs as contributing to their compassion fatigue, burnout, and secondary traumatic stress were at the societal and structural levels, while the ProQOL focuses largely on individual-level feelings, cognitions, and behaviors. This suggests that the quantitative measure was not sensitive enough to capture compassion fatigue, burnout, and secondary traumatic stress among HCPs in the context of the COVID-19 pandemic.

Discussion

Our study’s contributions are threefold: (1) We describe safety concerns and value misalignment as factors characterizing stressors perceived to contribute to HCP compassion fatigue, burnout, and secondary traumatic stress during the COVID-19 pandemic; (2) we highlight the salience of societal and system stressors in HCPs’ experiences. Although this does not negate the potential existence of individual-level stressors, these were not emphasized by HCPs in this study. And (3) the discrepancy between our qualitative and quantitative findings calls attention to the challenges of clearly defining and accurately capturing and measuring compassion fatigue, burnout, and secondary traumatic stress, especially in light of the changes caused by the COVID-19 pandemic.

These findings add to the body of evidence that underscores HCP compassion fatigue, burnout, and secondary traumatic stress as significant challenges in the U.S. healthcare system, which have been exacerbated by the COVID-19 pandemic (Alanazi et al., 2022; Braquehais et al., 2020; Koontalay et al., 2021; Lluch et al., 2022). Additionally, our qualitative findings align with previous research indicating that COVID-related stressors such as the unpredictability of the pandemic, institutional stressors such as inadequate staffing, and societal stressors such as healthcare disparities are some of the underlying factors contributing to low HCP wellbeing (Shah et al., 2022; Zerden et al., 2022).

These findings carry important implications for practice, policy, and research, as HCP compassion fatigue, burnout, and secondary traumatic stress are associated with HCPs’ mental health, quality of patient care, error rate, malpractice claims, staff turnover, and patient dissatisfaction (Dasan et al., 2015; Pearman et al., 2020; Shah et al., 2022). Because of the profound impact the COVID-19 pandemic has had on all sectors of society globally, it is critical to revisit the theoretical models used to explain and assess HCPs’ wellbeing.

Much has been written about the role of social and structural factors on health and health disparities (Braveman & Gottlieb, 2014; Green et al., 2021; Singu et al., 2020). Studies specifically focused on how social and structural factors, during the COVID-19 pandemic, impacted HCPs are still few (Browne et al., 2023; Pathman et al., 2022). NASEM’s model of clinician burnout includes similar factors affecting HCPs’ wellbeing as this study (NASEM, 2019). This model includes three system levels: (1) External environment, which includes the healthcare industry, laws and regulations, and societal values; (2) Healthcare organization, which includes leadership and management, governance, rewards, and benefits; and (3) Frontline care delivery, which includes the physical environment, technologies, activities, and the people involved (clinicians, staff, learners, patients, and families). Additionally, it incorporates work system factors (job demands and job resources) and individual-level factors (NASEM, 2019). However, it is possible that by identifying societal values as a distal factor, it may be minimizing the central role that safety concerns and value misalignment have had on HCPs’ wellbeing during the pandemic. Literature that utilizes this framework is limited, and the ways in which COVID-19 fits within this model remain to be studied.

Further, the discrepancy between our qualitative and quantitative findings suggests the prevalence and severity of HCP compassion fatigue, burnout, and secondary traumatic stress may have been underestimated. This may be partially due to the focus on individual-level factors among existing measures that insufficiently capture the structural components of burnout at the institutional or societal levels. An analysis of the psychometric properties of the ProQOL suggested validity and reliability concerns with the burnout and secondary traumatic stress scales (Hemsworth et al., 2018), which could help explain our participants low scores on these outcomes. Future research could utilize robust measures to augment quantitative prevalence studies with qualitative data so that they are sensitive to the current realities affecting HCPs, especially post-COVID-19.

Likewise, the focus of wellbeing measures and studies on HCP individual-level factors has most likely informed suggested interventions that are individual in nature such as self-care or mindfulness (Babineau & Thomas, 2019; Sharifi et al., 2021). Interventions that fail to address the systemic challenges discussed by participants, such as inadequate staffing, would mean an incomplete and temporary relief to a problem that is much more deeply rooted. Additionally, it would also risk overburdening the individual HCP with the responsibility of surviving a system that is not structured in a supportive way. Existing evidence supports this recommendation, as interventions focused on workload or scheduling changes have been found more effective at reducing burnout than physician-level interventions focused on mindfulness or stress reduction (De Simone et al., 2021; Shanafelt & Noseworthy, 2017). Therefore, any meaningful effort to decrease the current rates of HCP compassion fatigue, burnout, and secondary traumatic stress must consider the values and policies embedded in what the system asks of HCPs, particularly when caring for patients suffering from health inequities.

Limitations

This study is not without limitations. First, due to it being part of a program evaluation that used purposive sampling, quantitative findings are not considered generalizable beyond the HCPs that participated in this study. Second, we were unable to compare ProQOL scores of compassion fatigue, burnout, and secondary traumatic stress across healthcare professions due to the small sample size. Third, the sample lacked racial diversity, and although it included HCPs from diverse professional backgrounds, it was overrepresented by physicians. The variability in focus group size and the inclusion of interviews in the focus group data are additional limitations, which resulted from the challenges of recruiting HCPs during the COVID-19 pandemic. Future studies should include a larger, more representative sample of healthcare professionals from a variety of departments and disciplines, as well as more racially and ethnically diverse sample. Further, future studies should consider including several measures for burnout, compassion fatigue, and secondary traumatic stress to compare their efficacy at identifying and measuring structural factors such as systems-level or institutional-level stressors.

The lack of clear, shared definitions of compassion fatigue, burnout, and secondary traumatic stress is a limitation of our study as well as of the literature in general (Dean et al., 2020; Sabo, 2006; Schaufeli, 2021; Schwenk & Gold, 2018). HCPs’ narratives indicated their experience of all three conditions according to Stamm’s (2010) definitions, hence our decision to keep all three outcomes. Future studies should focus on more clearly specifying definitions for these and other outcomes indicative of professional quality of life.

Conclusion

The COVID-19 pandemic has exacerbated HCP compassion fatigue, burnout, and secondary traumatic stress by contributing to a work environment in which HCPs were constantly managing safety concerns while grappling with the frequent misalignment between their values and those of the institution and greater society. Taking a structural orientation to all efforts around HCPs’ wellbeing—research, policy, and administration—is fundamental if we are to adopt genuine, long-term solutions.

Footnotes

Acknowledgments

The authors are grateful to the HCPs who participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Michael and Susan Dell Foundation and Texas Mutual.

Ethical Statement

ORCID iDs

Ana A. Chatham

Tim Mercer

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